LDI Charles Leighton, MD Memorial Lecture

1. E EM
Q AS
IR
A M
R OM
High Value Cost Conscious
g IS
S IO
N
F
RM
Care: Is it Rationing or
EN
PE
T
IT
Rational C O?WR
R i l Care?R
PRI
O UT
H
IT
W
E
UT Qaseem, MD PhD MHA
Amir Qaseem MD, PhD, MHA, FACP
B
T RI
IS
Director, Clinical Policy, American College of Physicians
D
O R Chair, Guidelines International Network
RE
S HA
NOT
DO

2. E EM
Q AS
IR
Conflicts of Interest A M
R OM
F
N
 Financial: SIO
IS
 Employee of the American CollegeMof Physicians
ER
P
 No other financial conflicts TE N
T
RI
W
OR
RI
 Non-financial: UT
P
OH
 Guidelines International Network
IT
W
T E
 Institute ofUMedicine
B
T RI
 Centers for Disease Control and Prevention
IS D
OR
RE
S HA
NOT
DO

3. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO

4. E EM
AS
Cost of Health Care in the US A M
IR
Q
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
T
NO
CMS, Office of the Actuary, National Health Statistics Group
DO

5. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT Reinhardt, NY Times, 12/24/2010.
DO

6. E EM
AS
Diagnostic Imaging Studies in 6 LargeMIR Q
A
Integrated Health Care System R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT Smith-Bindman R et al. JAMA. 2012;307:2400-2409.
DO

7. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO

8. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO

9. E EM
AS
Overtreatment A M
IR
Q
R OM
F
N
IO
 Unnecessary treatment IS
S
RM
 End of life care PE
T EN
 Excessive use of antibiotics R IT
W
 Generic vs non-generics OR or higher-priced
PRI
T
services vs l
i lessHexpensive alternates
OU i lt t
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO

10. E EM
AS
End of Life: Where Do Patients AMIR Q
Die? OM
FR
N O
 Hospital: ~53%
53% SI
IS
E RM
P
 Nursing home: ~24% TEN
R IT
W
 Home: ~24% OR
PRI
 Data f
D t from UT t di
other studies:
th HO
IT
W
T E
 Survey
y data: 60-80% of people want to die
U p p
B
at home T RI
IS D
OR
 ~22%
22%
RE of people die in an ICU
S HA
NOT
Gruneir A et al. Med Care Res Rev. 2007; 64:351
DO

11. E EM
AS
The Cost of Wasted Resources and A M
IR
Q
Unnecessary Diagnostic Testing OM
FR
N O
SI
IS
E RM
 Current waste: an estimated N$750 billion loss P
in 2009 (IOM 2012) T TE
RI
W
 Inappropriate diagnostic O R testing (i.e. testing
PRI
that is overused or OU
Tmisused) is estimated to
H
IT
cost approximately $210 billion per year (10%
W
E
UT
of annual Ihealth care costs)
B
T R
(PriceWaterhouse (www.pwc.com)
D IS
OR
RE
S HA
NOT
DO

12. E EM
AS
Excess Costs Domain EstimatesAMIR Q
(30% of Health Care Costs) N FR OM
O
Cost in Billions of $$$
Cost in Billions of $$$ SI
IS
E RM
P Unnecessary Services
$75 TEN ($210 B)
$210 R IT Inefficiently Delivered
$55 W
OR
Services ($130 B)
PRI Excess Administrative
$105
$105
O UT Costs ($190 B)
Costs ($190 B)
H Excessive Pricing ($105 B)
IT
W
U TE $130
$130 Missed Prevention
R IB Opportunities ($55 B)
I ST$190 Fraud ($75 B)
D
OR
RE
S HA
NOT The Healthcare Imperative 2010
IOM
DO

13. E EM
AS
According to the IOM report A M
IR
Q
R OM
F
ON
 If banking worked like health care, ATM transactions
g , SI
IS
would take days. RM
PE

T EN
If home building were like health care, carpenters,
electricians and plumbers would work f
l ti i d l b ld
R IT k from diffdifferent
t
W
blueprints. OR
PRI
 If shopping were like health care, prices would not be
T
posted and could vary H OUwidely within the same store,
IT
W
depending on who was paying.
E
UT
 If airline t RIBl were lik h lth care, i di id l pilots
i li travel like health individual il t
T
would beISD free to design their own preflight safety checks
— or OR perform one at all.
E
not p
AR
SH
NOT
DO

14. E EM
AS
Are We Willing (and Able) to AMIR Q
Address the Problem? OM
FR
N O
SI
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO

15. E EM
AS
It Is Our Ethical and ProfessionalIR AM
Q
Responsibility to Control Cost! OM
FR
N O
SI
From Medical Professionalism in the New Millennium: A IS
RM
PE
Physician Charter (ABIM-F, ACP-F, EFIM)
EN
“While meeting the needs of individual patients, physicians
T
are required to provide health care R IT that is based on the
W
OR
wise and cost-effective management of limited clinical
resources.” P RI
T
OU
“The physician’s professional responsibility for appropriate
H
IT
allocation of resources requires scrupulous avoidance of
W
E
p UT
superfluous tests and p procedures. The provision of
p
R IB
unnecessary services not only exposes one’s patients to
ST
DI
avoidable harm and expense but also diminishes the
OR
resources available for others.”others.
E
AR
SH
T
OAnn Intern Med. 2002; 136:243-246
N
DO

16. E EM
AS
Physician Controlled Costs A M
IR
Q
R OM
F
N
 Unnecessary testing SIO
IS
and treatment $210B RM
PE
 Inefficiently delivered
y T EN
R IT
care $130B W
OR
RI
 Missed prevention T P
p
opportunities $55B H OU
IT
W
 Total = $395B E
UT B
T RI
S
DI
OR
RE
S HA
NOT
DO

17. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO

18. E EM
AS
Why is there an overused or A M
IR
Q
misuse? R OM
F
N
 Lack of  IO
Clinical performance
S
IS
guidance/guidelines measures RM
PE
T EN
 Lack of knowledge  RIT
Discomfort with
W
R diagnostic uncertainty
Insecurity about IO
 PR
clinical skills
li i l kill O UT  Discontinuity of care
Di ti it f
H
IT
W
 Patient expectations E  Inadequate time with
BUT
RI patients
 Fear of ST
Imalpractice
D
O R
E  Habits
 PARPersonal gainl i
S H
T
NO
DO

19. E EM
AS
Financial Incentives Can Drive AMIR Q
Behavior OM
FR
N
Stress Testing Within 30 Days of Outpatient Visit After
O
SI
Coronary R
C Revascularization (%)
l i i IS
M
P ER
EN
30
T T
25 RI
W
OR
RI
20
P
15
O UT Tech+Prof
H Fee
IT
10 W Prof Fee
UTE Only
5
R IB No Billing
ST
0 DI
R
ONo Symptoms CABG PCI Overall
RE
Symptoms
S HA
T
NO BR et al. JAMA. 2011; 306:1993
Shah
DO

20. E EM
AS
Financial Incentives Can Drive AMIR Q
Behavior OM
FR
N O
 S SI
A review of ownership of nuclear Imyocardial
perfusion studies among MedicareRM patients:
PE
T EN
 cardiologists
cardiologists’ offices increased 215% between
T
RI
1998 and 2006, W
O R
RI
 radiologists and other physicians increased 32%
P
T
OU
and 181% respectively
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
T
NO DC et al. J Am Coll Radiol. 2009;6(6):437-441
Levin
DO

21. E EM
AS
Financial Incentives Can Drive AMIR Q
Behavior OM
FR
N O
 Self employed
Self-employed urologists (who owned office- SI office
IS
based imaging equipment) were RM2 to 5 times
PE
g ITgT EN
more likely to order imaging for a variety of
y y
R
W
urinary conditions compared with those
OR
urologists who wereP in
g RI employment based
p y
T
OU
practice modelsH(salaried and not owning
IT
equipment)UTE W
B
T RI
S
DI
OR
RE
S HA
T
NO
Hollingsworth JM et al. J Urol. 2010;184(6):2480-2484
DO

22. E EM
AS
Physicians Lack Understanding About BenefitIR
Q
A M
of S
f Screening T
i Tests OM
FR
N
S IO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
OT
Wegwarth O et al. Ann Intern Med 2012;156:340-349
N
DO

23. E EM
AS
Ovarian Cancer Screening: A M
IR
Q
What are the Recommendations? OM
FR
N O
 D SI
Routine screening: “D” grade (USPSTF)
IS
E RM
 High risk (based on family Ehx.): referral for
N
P
genetic counseling and RITT BRCA testing
W
(USPSTF and ACOG) RI
O R
P
T
 +BRCA1 or +BRCA2: candidate f risk-
BRCA1 BRCA2
H OU did t for i k
IT
reducing surgery, not screening (Soc. Gyn.
E
W
UT
Onc.)
Onc ) RIB
T
D IS
O R
E
AR
SH
OT
Baldwin L-M, et al. Ann Intern Med. 2012; 156: 182.
N
DO

24. E EM
AS
Ovarian Cancer Screening: A M
IR
Q
What Do Physicians Think? N FR OM
O
 1/3 say transvaginal ultrasound or SI
IS
RM
Ca-125 is an effectiveEscreening PE
N
T
IT
test
t t W
R
OR
 Study used case g
y PRI vignettes
T
OU
 65% offered ITH screening to medium-risk
W
woman UT E
B
T RI
 29%Soffered screening
I to low-risk woman
D
O R
E
AR
SH
OT
Baldwin L-M, et al. Ann Intern Med. 2012; 156: 182.
N
DO

25. E EM
AS
Defensive Medicine A M
IR
Q
R OM
F
N
IO
 $45.6
$45 6 billion in 2008 for hospital and IS
S
RM 29: 1569-1577)
physician spending (Mello et al, Health Affairs 2010;
PE
EN
 Most common forms (Studdert et T JAMA 2005;293: 2609-2617)
RI
T al
al, 2609 2617)
W
 Over-ordering of diagnostic tests O R
PRI
 Unnecessary referrals T
H OU
 Avoidance of WIT high-risk patients
U TE
R IB
ST
DI
OR
RE
S HA
NOT
DO

26. E EM
AS
Defensive Medicine A M
IR
Q
R OM
F
N
IO
 “when doctors order tests procedures or
when tests, procedures,
IS
S
visits, or avoid certain high-risk patients or RM
PE
p
procedures, p , primarily ( ITT
y (but not EN solely) because
y)
R
W
of concern about malpractice liability --- US
OR
g PRI
Congress Office ofT Technology Assessment gy
H OU
 Says nothing about the damages that patient
IT
W
T E
could incurUfrom excess or unnecessary y
B
screening T RI
IS D
OR
RE
S HA
NOT
DO

27. E EM
AS
Do Physicians Agree That A M
IR
Q
Healthcare is Overused? R OM
F
N
IO
Survey of primary care physiciansISS
E RM
 42% believe patients in theirPown practice
T EN
are receiving too much care (vs 6% who
R IT (vs.
W
say “too little”) O R
PRI
 Perceived factors T leading to overuse
OU H
IT
 Malpractice W
E
concerns: 76%
UT
 Cli i RIB f
Clinical performance measures: 52%
l
S T
DI
 Inadequate time to spend with patients: 40%
OR
RE
S HA
NOT Sirovich B et al. Arch Intern Med. 2011; 171:1582-1585
DO

28. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
OT
N Owens D; Qaseem A et al. Ann Intern Med. 2011; 154:174-180
DO

29. E EM
AS
Value = Benefits, Harms, Costs AMIR Q
R OM
F
 Value = benefit / (cost + harm) SIO
N
IS
 Cost ≠ Value RM
PE
EN
 Cost includes cost of testTand downstream T
RI
costs, benefits and harms W
O R
PRI
 High cost interventions may provide good
T
H OU
value because they are highly beneficial
W
IT
E
Low cost T
 Low-costUinterventions may have little or
B
T RI
no value if they provide little benefit or
D IS
R
increase downstream costs.
R E
O
S HA
OT
NOwens D; Qaseem A et al. Ann Intern Med. 2011; 154:174-180
DO

30. E EM
AS
Benefit, Cost, and Value A M
IR
Q
R OM
High Benefit F
Low Benefit
N O
SI
IS
M
High Anti-retroviral ER
Routine MRI for low
P
therapy for HIV N
backTpain
E
Cost T
RI
W
Value: high O RValue: low
PRI
O UT
Low HIV screening
H Annual pap smears
IT
Cost W
UTE
R IB
T
Value: high Value: low
D IS
OR
RE
S HA
OT
N Owens D; Qaseem A et al. Ann Intern Med. 2011; 154:174-180
DO

31. E EM
AS
Value Measurement: Quality MIR Q
A
Adjusted Life Years (QALYs)ROM
F
N
IO
 An important metric for measuring health
S
IS
RM
benefits by taking into accountEboth length
P
N
and quality of life
q y TE
ITR
W
I OR
PR
 Allows for comparison of interventions
UT
HO
IT
between different specialities (compare
W
E
UT
cancer treatments with cardiovascular
B
T RI
treatments)
D IS
OR
RE
S HA
NOT
DO

32. E EM
AS
Four interventions, A, B, C, D A M
IR
Q
R OM
F
A is better and cheaper
ND
IO
than
S
IS
E RM
P
TEN
R IT B is better than A b
i b h but
W more expensive
OR
PRI
O UT
H
IT
W
UTE C is better than B but
IB more expensive
T R
S
DI
OR
RE
S HA
OT
N Owens D; Qaseem A et al. Ann Intern Med. 2011; 154:174-180
DO

33. E EM
AS
Cost-Effectiveness Threshold: MIR
Cost- Q
A
How Much is Health Worth?ROM
F
N
 Threshold depends on who is making the S IO
IS
decision and their willingness toPpay for better E RM
health outcomes T EN
R IT
 National Health Service R in
WUK $30,000-$50,000/
O
QALY PRI
T
 No consensus in H USOU - citizens have been willing
IT
W
to pay up to $109,000/QALY, most US decision
E
BUT
k T RI id
makers consider interventions that cost l
i i h less than
h
S
DI
$50,000-$60,000/QALY high value
OR
RE
S HA
T
NO
DO

34. E EM
AS
QALY Examples A M
IR
Q
OM
Intervention Cost Effectiveness N FR Ratio
O
SI
Prevention M
P ti Measures IS
RM
High intensity smoking prevention $190/QALY E P
N
T TE
Screening 60 y o for Diabetes $ RI
$25,738/QALY
W
O R
RI
Treatments for existing
conditions P
T
ART for HIV OU $29,000/QALY
I TH
W
Implantation of defibrillators $52,000/QALY
U TE
oIB
Surgery in 70 y R male with Increased cost and worsens
T
prostate ca DIS health
OR
RE
S HA
T
NO
Cohen JT et al. N Engl J Med 2008;358:661-663
DO

35. E EM
AS
How Can We Reduce A M
IR
Q
Inappropriate Care? R OM
F
N
IO
 Develop guidance for physicians Iabout SS
appropriate use of care, focusing RM initially on
PE
diagnostic testing
g g T EN
IT R
 Assemble and integrateRevidence-based and
W
O
RI
consensus-based recommendations
P
 Ed
Educate t UT
t target audiences about areas of
t HO di b t f
IT
overuse andEmisuse of care:
W
 Trainees IB UT
(students, residents, and fellows)
(students residents
T R
IS
www.highvaluecarecurriculum.org
D
R
 Practicing clinicians
E
O g
R
APatients
SH
NOT
DO

36. E EM
AS
Key Features of Bringing Cost Consciousness IR
Q
A M
into the T i i E i
i h Training Environment OM
FR
N
 Approach: focus on appropriate careS S IO
rather than
I
saving money RM
PE
 Knowledge: understanding of EN T
what helps
h ti fl RIT
patients vs. what is superfluous or even harms
ti t W
h
patients OR
PRI
 Philosophy: recognition that more ≠ better
T
H OU
 Faculty development: trainees mimic faculty
IT
behavior TE W
U
 R IB
Assessment: of trainee knowledge and behavior
ST
 DI
Regulation: cost consciousness in residency
OR
competency requirements
RE
S HA
NOT
DO

37. E EM
AS
Towards High-Value Cost-Conscious Care
High- Cost- IR
Q
AM
M
Ocare
 Ask appropriate questions at the point of
FR
N
 Did the patient have this test previously? SIO
IS
 RM
Will the result of this test change the care of the
patient? PE
T EN

R IT
What are the probability and potential adverse
W
consequences of a false positive result?
OR
 Is the patient in potentialI danger in the short term if I do
PR
not perform thi t Ot?
t f UT
this test?
H
 Am I ordering W IT test primarily because the patient
the
wants it orUTEreassure the patient?
to
B
 Observe T RIand provide feedback to trainees on
D IS
their
O R provision of high value care- let them
E
AR
H know if they are wasting resources!
S
NOT
DO

38. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
IdentifiesIST clinical situations in which a screening or
37
D
diagnostic test does not reflect high value care.
R O
RE
S HA
T
OQaseem et al. Ann Intern Med. 2012; 156:147-149.
N
DO

39. E EM
AS
Overused Dx Tests A M
IR
Q
R OM
F
 Screening for colorectal cancer in adults ON
SI
older than 75 y or in adults withRa life IS
M
PE
expectancy of less than 10 yN
T TE
 Performing imaging studies RI in patients with
W
O R
nonspecific low backRIpain P
UT
 Ordering routine O H preoperative laboratory
IT
W
tests, including complete blood count, liver
E
UT
chemistryIB TR tests, and metabolic profiles, in f
S
DI
otherwise healthy patients undergoing
OR
l RE ti
elective surgery
HA
S
T
NO
DO

40. E EM
AS
Overused Dx Tests A M
IR
Q
R OM
F
N
Performing brain imaging studies (CT Ior MRI) to IO
 SS
evaluate simple syncope in patients RM normal E with
P
findings on neurologic examination N
T TE
 Obtaining CT scans in a patient RI with pneumonia that
W
O R
is confirmed by chest radiography in the absence of
RI
P
complicating clinical U T radiographic features
or
H O
 Performing imaging IT studies, rather than a high-
W
E
DBUT
sensitivity D-dimer measurement, as the initial
dimer
I
diagnosticRtest in patients with low pretest probability
IS
T
D
of venous thromboembolism
O R
RE
S HA
NOT
DO

41. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
T
OChou R; Qaseem A; et al Ann Intern Med. 2011; 154:181-189
N
DO

42. E EM
AS
Example of Healthcare Waste A M
IR
Q
R OM
F
N
IO
 Patient with uncomplicated back pain without IS
S
any red flags RM
PE
EN
 Total cost of workup and RITT treatment done in
W
this case (plain films, IMRI, physical therapy):
O R
PR
$10,821.93 T
H OU
IT
 Total cost of workup and treatment that would
W
E
UT
be recommended by ACP guideline : $908
IB R
T
DIS
OR
RE
S HA
NOT
DO

43. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
EN T
 I addition t measure underuse of care,
In dditi to RdIT f
W
need to develop evidence-based OR
PRI
T
performance measures to assess use of low low-
H OU
value interventions IT
W
E
UT
 ServicesIBwhere harm exceeds the zero to
R
ST
negligible benefit
DI
OR
RE
S HA
T
NO Baker D; Qaseem A et al. Ann Intern Med. 2013; 158
DO

44. E EM
AS
Patient Education A M
IR
Q
R OM
 Shared-decision making N
F
O
SI
 Involve patients and their familiesS M
I
P ER
 According to a recent IOM report:
N
E T
 69 percent patients want th
t ti t t WR ITi provider t t ll th
their id to tell them
OR
the risks of the treatment options so they will know
PRI
how each might affect them T
OU
 53 percent wantHto know about each option’s cost
IT
W
to themselves E and their family.
BUT
 47 percent T RI patients want their health care provider
IS
to OR D
discuss the option of not pursuing a test or
tE t
Atreatment
R t
SH
T
OIOM 2012. Communicating with patients on health care evidence.
N
DO

45. E EM
AS
Patient Education A M
IR
Q
R OM
 Annals of Internal Medicine Summaries for N
F
O
Patients SI
IS
RM
http://www.acponline.org/clinical_informati PE
T EN
on/guidelines/ R IT
W
 ACP Foundation’s Health TiPS OR
PRI
T
 Collaborations with consumer
OU
H
IT
organizations (e.g., Consumer Reports)
W
E
that include BUT videos and educational
T RI
IS
materials
D
OR
RE
S HA
NOT
DO

46. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
S T
DI
OR
RE
S HA
N OT
http://www.consumerreports.org/cro/2012/04/best-health-tests-and-treatments-
often-cost-less/index.htm
DO

47. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO

48. E EM
AS
Options?? A M
IR
Q
R OM
F
N
IO
 Patients share the financial burden
burden… IS
S
RM
PE
 Financial incentives for physicians and
T EN
change in the reimbursement system
R IT system….
W
 Team-based care….RIO R
P
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO

49. E EM
AS
Hurdles?? A M
IR
Q
R OM
F
N
IO
 Litigation system IS
S
RM
 Transparency (costs, charges,Eetc)N
P
T TE
 Heterogeneity in circumstances
RI
W
R
 Anecdotal evidence RIO
P
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO

50. E EM
AS
Recommendations for High-
High- IR
Q
A M
V l C -C
Value Cost Conscious C
Cost- i Care FROM
N
S IO
 Understand the benefits, harms and relative costs of the
benefits harms, IS
M
interventions that you are considering ER
P
N
Decrease or eliminate the use of interventions that provide

T TE
no benefits and/or may be harmful RI
W
 Choose interventions and care O R settings that maximize
P RI
benefits, minimize harms, and reduce costs (using
, T, ( g
OU
comparative effectiveness and cost effectiveness data)
H
IT
 W
Customize a care plan with the patient that incorporates
E
their valuesIBUT addresses their concerns
and
R
 ST
Identify Isystem level opportunities to improve outcomes,
D
R
minimize harms, and reduce healthcare waste
O
RE
S HA
NOT
DO

51. E EM
Q AS
 Issue of the decade starting in 2010: M
IR
A
decreasing the cost of care
f OM
FR
 The rise in health care costs is notSION
IS
sustainable RM
PE
 Cost containment measures N happenTE will
T
RI
 Costs can not be controlled unless
R
W
IO
Rsubstantially reduced
inappropriate care Tis
P
OU
 Why should youHcare about cost?
IT
W
 Physicians
y U TE
responsible for 87% of spending
p p g
B
RI T
 Physicians can be part of the solution or
D IS
R
viewed as part of the problem
R E
O
S HA
NOT
DO

52. E EM
AS
Conserving resources through AMIR Q
M
providing high value care does N
FR
Onot
IO
mean rationing! RM
IS
S
PE
 Rationing: decisions are made about the EN
T
allocation of scarce medical
ll ti f diR IT l resources and
d
W
OR
who receives them, leading to underuse of
PRI
potentially appropriate care T
H OU
IT
 Rational or high value care: assuring that
E
W
UT
care is clinically effective thus avoiding
RI
B effective,
T
overuse D IS or misuse of care that is
O R
inappropriate
AR
E
SH
OT T; Qaseem A et al. Arch Intern Med. 2012
N Wilt
DO

53. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO